The Royal Australian
and New Zealand
College of
Obstetricians and
Gynaecologists
Birth after previous caesarean section
This statement has been developed and reviewed by
the Women’s Health Committee and approved by
the RANZCOG Board and Council.
A list of Women’s Health Committee Members can
be found in Appendix A.
Disclosure statements have been received from all
members of this committee.
Disclaimer This information is intended to provide
general advice to practitioners. This information
should not be relied on as a substitute for proper
assessment with respect to the particular
circumstances of each case and the needs of any
patient. This document reflects emerging clinical
and scientific advances as of the date issued and is
subject to change. The document has been
prepared having regard to general circumstances.
Objectives: To provide those women who have
previously been delivered by Caesarean section, their
partners, doctors and midwives with information
regarding the benefits and risks of their options for
delivery, vaginal birth or repeat elective Caesarean
section.
Target audience: Health professionals providing
maternity care, and patients.
Values: The evidence was reviewed by the Women’s
Health Committee (RANZCOG), and applied to local
factors relating to Australia and New Zealand.
Background: This statement was first developed by
Women’s Health Committee in July 2010 and
reviewed in July 2015.
Funding: The development and review of this
statement was funded by RANZCOG.
First endorsed by RANZCOG: July 2010
Current: July 2015
Review due: July 2018
1
Table of contents
1.
Terminology ............................................................................................................................. 3
2.
Patient Summary ....................................................................................................................... 3
3.
Summary of recommendations ................................................................................................... 4
4.
Introduction .............................................................................................................................. 5
5.
Discussion and recommendations............................................................................................... 6
5.1 Past history and suitability for VBAC.......................................................................................... 6
5.2 Success Rates ......................................................................................................................... 7
5.3 Benefits and risks of VBAC....................................................................................................... 8
5.4 Benefits and risks of ERCS at 39 weeks ..................................................................................... 8
5.5 Uterine Rupture ...................................................................................................................... 9
5.6 Perinatal Mortality ................................................................................................................ 10
5.7 Hypoxic Ischemic Encephalopathy (HIE) .................................................................................. 10
5.8 Risks associated with ERCS .................................................................................................... 11
5.9 Intrapartum Recommendations .............................................................................................. 12
5.10 Induction and augmentation in labour .................................................................................. 14
6.
Special Circumstances ............................................................................................................. 15
6.1 Trial of labour after more than one previous Caesarean section ............................................... 15
6.2 Twin Gestation ..................................................................................................................... 15
6.3 Midtrimester delivery ............................................................................................................. 16
7.
Conclusion ............................................................................................................................. 16
USEFUL LINKS USED IN THE WRITING OF THIS STATEMENT ........................................................... 17
LINKS TO OTHER COLLEGE STATEMENTS ..................................................................................... 17
REFERENCES ................................................................................................................................. 19
Appendices ................................................................................................................................... 23
Appendix A Maternal Morbidity of Women Who Had Caesarean Deliveries Without Labour 59 .......... 23
Appendix B Outcomes of VBAC comparing patients with one previous caesarean section with those
multiple previous caesarean sections. ........................................................................................... 24
Appendix C Women’s Health Committee Membership ................................................................... 26
Appendix D Overview of the development and review process for this statement .............................. 26
Appendix E Full Disclaimer .......................................................................................................... 28
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1.
Terminology

VBAC: Successful vaginal birth following labour in a woman who has had a prior Caesarean section
delivery.

PLANNED VBAC: Planned labour with a view to safe vaginal birth in a woman who has had a prior
Caesarean section delivery. Also referred to by some authors as Trial of Labour (TOL) or Trial of Labour
after Caesarean (TOLAC) or Next Birth after Caesarean (NBAC).

ERCS: Elective repeat Caesarean section. Planned Caesarean section in a woman who has had one or
more previous Caesarean sections.

PERINATAL MORTALITY: The combined number of still births (antepartum and intrapartum) and
neonatal deaths (death of a live infant from birth to the age of 28 days).

HYPOXIC ISCHAEMIC ENCEPHALOPATHY (HIE): Neurological changes caused by lack of sufficiently
oxygenated blood perfusing brain tissue resulting in compromised neurological function manifesting
during the first few days after birth. HIE may be associated with multiple organs damaged by similar
perfusion injuries.
•
NEONATAL RESPIRATORY MORBIDITY: The combined rate of transient tachypnoea of the newborn
(TTN) and respiratory distress syndrome (RDS).

UTERINE RUPTURE: A disruption of the uterine muscle extending to and involving the uterine serosa or
disruption of the uterine muscle with extension into bladder or broad ligament.

UTERINE SCAR DEHISCENCE: A disruption of the uterine muscle with intact uterine serosa.

PLACENTA ACCRETA: Densely adherent placenta due to abnormally deep invasion of the placenta into
the uterine muscle and sometimes growing through the full thickness of the uterine wall to the outside of
the uterus.

LUSCS: Lower Uterine Segment Caesarean Section.

RCOG: Royal College of Obstetricians and Gynaecologists.

ACOG: American Congress of Obstetricians and Gynaecologists.

SOGC: Society of Obstetricians and Gynaecologists of Canada.
2.
Patient Summary
Many women will need to decide on the mode of birth for subsequent pregnancies after a caesarean
section. Each option – either labour with a view to safe vaginal birth, or planned Caesarean section - has
both potential risks and benefits. Each individual woman’s preferences and risk profiles will be different.
Involvement of the woman and her family in this decision making is strongly supported. Those who provide
maternity care - doctors and midwives - need to provide women and their partners with accurate and
relevant information.
It can be challenging to explain and understand the risk of complications which occur rarely, but with very
serious consequences when they happen. Attempting vaginal birth after a previous Caesarean section
carries the additional risk for mother and baby of uterine scar rupture, an event that occurs approximately
five to seven times in every 1000 attempts. If this does occur, there is approximately a one in seven chance
of serious adverse outcome (death or brain injury) for the baby. When repeat elective Caesarean section is
chosen there are the risks associated with major surgery, and a commitment to future Caesarean delivery is
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likely. As the number of her previous Caesarean section deliveries increases, so does the risk of rare but
serious complications. The benefits and risks of each birth option and the factors affecting the chances of
success for planned VBAC are discussed in this statement.
An agreed plan of management for birth should be made during a woman’s pregnancy and be documented
in the medical record. Women who choose to labour with a view to the safest possible vaginal delivery
should be managed in an obstetric unit with trained staff and the appropriate equipment to monitor the
mother’s and fetus' wellbeing continuously throughout the labour, and has the facility to proceed to urgent
Caesarean section if required. Epidural analgesia may be used.
Some special circumstances such as women who have had more than one Caesarean delivery, twin
pregnancy and induction of labour in mid trimester are discussed.
3.
Summary of recommendations
Recommendation1
Grade
Early in the postnatal period following a primary Caesarean delivery, women
should be offered the opportunity to be debriefed and to discuss their birth
experience, as well as their potential suitability for planned VBAC in future
pregnancies.
Consensus-based
recommendation
Recommendation 2
Grade
Women with a prior history of an uncomplicated lower segment Caesarean
section, in an otherwise uncomplicated pregnancy, should be given the
opportunity to discuss the birth options of planned VBAC or elective
Caesarean section early in the course of their antenatal care.
Consensus-based
recommendation
Recommendation 3
Grade
The risks and benefits of the birth options, considered in conjunction with an
individual woman’s chances of success for VBAC, should be discussed with the
patient and documented in the medical record. The provision of a patient
information leaflet or other similar resource at the consultation is
recommended.
Consensus-based
recommendation
Recommendation 4
Grade
Respect should be given to the woman’s right to be involved in the decision
making regarding mode of birth, considering her wishes, her perception of the
risks and her plans for future pregnancies.
Consensus-based
recommendation
Recommendation 5
Grade
Attempts should be made, where possible, to check the operative record of the
previous Caesarean section, its indication and post-operative course.
Consensus-based
recommendation
Recommendation 6
Grade
Women considering options for birth after a previous Caesarean section should
be informed that ERCS may increase the risk of serious complications in future
pregnancies.
Consensus-based
recommendation
Recommendation 7
Grade
A final decision regarding mode of birth should be agreed between the woman
and her obstetrician (and midwife where appropriate) before the
expected/planned delivery date (ideally by 36 weeks gestation). A plan in the
event of labour starting prior to the scheduled date should be agreed and
documented.
Consensus-based
recommendation
Recommendation 8
Grade
Women should be advised that a planned VBAC should be conducted in a
suitably staffed and equipped delivery suite, with continuous intrapartum care
and monitoring and with available resources for urgent Caesarean section and
Consensus-based
recommendation
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advanced neonatal resuscitation should complications such as scar rupture
occur.
Recommendation 9
Grade
Continuous intrapartum care is required to monitor progress and to enable
prompt identification and management of uterine scar rupture.
Consensus-based
recommendation
Recommendation 10
Grade
Women should be advised to have continuous electronic fetal monitoring
following the onset of uterine contractions and for the duration of the planned
VBAC.
Consensus-based
recommendation
Recommendation 11
Grade
Epidural anaesthesia is not contraindicated in a planned VBAC.
Consensus-based
recommendation
Recommendation 12
Grade
Early diagnosis of the serious complication of uterine scar rupture followed by
expeditious laparotomy and resuscitation is essential to reduce the associated
morbidity and mortality for mother and infant.
Consensus-based
recommendation
Recommendation 13
Grade
If induction of labour is required in a patient with a previous Caesarean section,
the benefits and risks of planned VBAC should be reconsidered with alternatives
discussed.
Consensus-based
recommendation
Recommendation 14
Grade
Prostaglandins are not recommended for the induction of planned VBAC at
term.
Consensus-based
recommendation
Recommendation 15
Grade
Augmentation of labour with oxytocin in planned VBAC should be performed
with caution, and should involve a consultant-led discussion with the risks and
benefits discussed with the patient then documented in the clinical record.
Consensus-based
recommendation
Recommendation 16
Grade
Pregnancy after Caesarean section should be subject to multi-disciplinary
clinical audit, including assessment of the number of women opting for planned
VBAC versus ERCS as well as the number achieving VBAC. Quality of
adherence to agreed protocols should form part of the clinical audit.
Consensus-based
recommendation
4.
Introduction
In recent decades the Caesarean section rates have continued to rise; to 32% of births in Australia in 2011
and 23.6% of births in New Zealand in 2010.1, 2 As a consequence there are increasing numbers of women
who need advice regarding options for birth in subsequent pregnancies. Each option, elective Caesarean
section or labour with a view to vaginal birth, has its benefits and risks. Patient differences give rise to a
variation of patient preference, risk spectrum and of success rates for vaginal birth. Patients and clinicians
conjointly need to consider the options with a view to planning mode and place of birth for each mother
who has had a previous Caesarean delivery. There are no large prospective randomised controlled trials
assessing birth options.3 There are large numbers of reports which are mainly retrospective studies,
predominantly originating in North America, the UK and Europe which provide some evidence of which to
base decision making, but these are subject to variation both of population and management. There have
been at least three Australian studies and two New Zealand studies reporting local outcomes.4-8
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5.
Discussion and recommendations
5.1 Past history and suitability for VBAC
5.1.1
That a woman should be well informed regarding mode of birth after previous Caesarean
section and have the right to have her wishes respected is strongly supported by RANZCOG
and other similar professional bodies.9-11
5.1.2
It is appropriate that the counselling process begins after the primary caesarean section, ideally
before discharge from hospital. Ideally, it should be conducted by the doctor who performed
the caesarean section and, where appropriate, the midwife who cared for the patient during
her labour. The reason for the caesarean section and any unexpected issues occurring before,
during or after the surgery should be discussed, particularly any that would affect the woman’s
suitability for VBAC in future pregnancies. Advice which could increase the success and safety
of planned VBAC, such as an inter-delivery interval of at least 18 months and weight reduction
for overweight and obese patients should be provided. 12-16 This debrief would also provide an
opportunity to address any emotional needs, particularly for patients who found the experience
traumatic. If a woman was not feeling ready for this discussion before discharge from hospital,
a review early in the postnatal period would be worthwhile.
5.1.3
Studies of women who have faced the decision regarding mode of birth after previous
caesarean delivery have reported that a significant number of women found the decision
difficult – balancing their wishes against the interests of their child. 17 The potential risks and
benefits need to be discussed in the context of the woman’s individual circumstances, including
her personal motivation and preferences to achieve vaginal birth or ERCS, her attitudes to the
risk of rare but serious adverse outcomes, her plans for future pregnancies and her chances of
successful VBAC.
Recommendation1
Grade
Early in the postnatal period following a primary Caesarean delivery, women
should be offered the opportunity to be debriefed and to discuss their birth
experience, as well as their potential suitability for planned VBAC in future
pregnancies.
Consensus-based
recommendation
Recommendation 2
Grade
Women with a prior history of an uncomplicated lower segment Caesarean
section, in an otherwise uncomplicated pregnancy, should be given the
opportunity to discuss the birth options of planned VBAC or elective Caesarean
section early in the course of their antenatal care.
Consensus-based
recommendation
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Recommendation 3
Grade
The risks and benefits of the birth options, considered in conjunction with an
individual woman’s chances of success for VBAC, should be discussed with the
patient and documented in the medical record. The provision of a patient
information leaflet or other similar resource at the consultation is
recommended.
Consensus-based
recommendation
Recommendation 4
Grade
Respect should be given to the woman’s right to be involved in the decision
making regarding mode of birth, considering her wishes, her perception of the
risks and her plans for future pregnancies.
Consensus-based
recommendation
Recommendation 5
Grade
Attempts should be made, where possible, to check the operative record of the
previous Caesarean section, its indication and post-operative course.
Consensus-based
recommendation
Recommendation 6
Grade
Women considering options for birth after a previous Caesarean section should
be informed that ERCS may increase the risk of serious complications in future
pregnancies.
Consensus-based
recommendation
Recommendation 7
Grade
A final decision for mode of birth should be agreed between the woman and
her Obstetrician (and midwife where appropriate) before the expected/planned
delivery date (ideally by 36 weeks gestation). A plan in the event of labour
starting prior to the scheduled date should be agreed and documented.
Consensus-based
recommendation
5.2 Success Rates
5.2.1
There has been a wide range of success rates (23 - 85%) reported for those achieving vaginal
birth following a planned VBAC.4, 6, 18-21 Published studies of the outcomes for women
attempting VBAC report a likelihood of success of between 60 and 80% .10 A study from
Middlemore Hospital in New Zealand reported a 73% success rate, and one from 14
Australian hospitals reported a success rate of 43%.6, 7
5.2.2 Factors affecting success
FAVOURING SUCCESS




Previous safe vaginal birth.
Previous successful VBAC.
Spontaneous onset of labour.
Uncomplicated pregnancy without other risk
factors.
5.2.3
REDUCING SUCCESS









Previous Caesarean section for dystocia.
Induction of labour.
Coexisting fetal, placental or maternal
conditions22
Maternal BMI greater than 30 Kg/m2.
Fetal macrosomia of 4 kg or more.
Advanced maternal age.
Short stature.
More than one previous Caesarean section.
Risk factors associated with an increased risk of
uterine scar rupture (see below).
Previous vaginal birth, especially successful VBAC, is the strongest predictor of success, with
VBAC rates of 87-91% reported in that group.7, 18, 19, 23
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5.2.4
Induced labour, no previous vaginal birth, a BMI greater than 30 Kg/m2, and previous
Caesarean section for dystocia are factors that all reduce the success rate; Landon reported if
all four are present then the success rate was only 40%.18
5.2.5
For the mordidly obese patient (BMI>40 Kg/m2) the chances of a unsuccessful VBAC and of
uterine rupture are significantly increased. Hiddard, in a prospective observational study of
14,142 patients undergoing VBAC, reported unsuccessful trial of labour in 15.2% of those of
normal weight (1344 women) compared to 39.3% for those with a BMI≥40 Kg/m2 (1,344
women) (p< 0.001), with the incidence of uterine rupture/dehiscence being 0.9% compared
to 2.1% (p=0,03).24
5.2.6
Other factors which have been reported to adversely affect success rates are gestational age
beyond 41 weeks, fetal macrosomia, advanced maternal age, short stature, and fetal
malpresentation.18-21, 25
Clinicians may find the online NICHD MFMU calculator for predicting successful VBAC useful.
This resource can be accessed at:
https://mfmu.bsc.gwu.edu/PublicBSC/MFMU/VGBirthCalc/vagbirth.html.
This calculator estimates likelihood of VBAC success according to variables such as maternal
age, BMI, and indication for previous Caesarean section, and is based on the equation
published by NICHD MFM Units Network.26 While other factors may influence likelihood of
success, clinicians may find this calculator useful when counselling patients regarding their
individualised likelihood of success.
5.3 Benefits and risks of VBAC
BENEFITS IF SUCCESSFUL VBAC




Less maternal morbidity for index pregnancy
and future pregnancies.
Avoidance of major surgery.
Earlier mobilisation and discharge from
hospital.
Patient gratification in achieving vaginal birth if
this is desired.
RISKS




Increased perinatal loss compared with ERCS at
39 weeks(1.8 per 1000 pregnancies)
Stillbirth after 39 weeks gestation (due to
longer gestation).
Intrapartum death or neonatal death (related
to scar rupture in labour).
HIE risk (0.7 per 1000).
Related both to labour and vaginal birth and
to scar rupture.
Increase morbidity of emergency Caesarean
section compared to ERCS if unsuccessful in
achieving VBAC.27, 28
Pelvic floor trauma.
5.4 Benefits and risks of elective repeat Caesarean section at 39 weeks
BENEFITS




Avoid late stillbirth (after 39 weeks).
Reduced perinatal mortality and morbidity
(especially HIE) related to labour, delivery and
scar rupture.
Reduced maternal risks associated with
emergency Caesarean section.
Avoidance of trauma to the maternal pelvic
RISKS



Surgical morbidity and complications both with
index pregnancy and further pregnancies.
Increased risk of neonatal respiratory morbidity –
low incidence ≥ 39 weeks gestation.
Associated with lower rates of initiating breast
feeding 29-31
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
floor.
Convenience of planned date for birth.
5.5 Uterine Rupture
5.5.1 Uterine rupture in an unscarred uterus is extremely rare, with incidence rates estimated at 0.52.0 per 10,000 deliveries, and occurrence mainly confined to multiparous patients in labour. 32
The incidence of scar rupture in a patient undergoing VBAC has been reported between 22 and
74 per 10,000 births.9, 33, 34
5.5.2 Chauhan et al reviewed maternal and perinatal complications from 142,075 patients who
attempted vaginal birth after Caesarean section delivery. 35 They reported a uterine rupture rate
of 6.2/1,000 trials of labour. The uterine rupture-related complication rate was 1.5 per 1,000
for pathological fetal acidosis (a cord pH < 7.00), 0.9/1000 for hysterectomy, 0.4/1,000 for
perinatal death, and 0.02/1,000 for maternal death. These figures are consistent with a large
Australian retrospective analysis and review of 10 international series where the likelihood of
uterine rupture of attempted vaginal delivery after previous lower segment Caesarean section
was estimated at 5/1,000, and the perinatal death from uterine rupture at 0.7/1,000 women
attempting VBAC.4 Landon, in a prospective observational study from 19 academic centres in
the United States, reported a symptomatic uterine rupture rate of 7/1,000 from a total of
17,898 women who planned VBAC, and the occurrence of HIE in seven babies related to
uterine rupture (0.4/1000). 33 The overall complication rates related to scar rupture per 1000
women attempting VBAC for the three series is summarised in the table below: 4 33, 35
TABLE 1: The complication rates related to scar rupture per 1000 women attempting VBAC4, 33,
35
COMPLICATION
Uterine rupture
Perinatal death
Maternal death
Major maternal morbidity
• Hysterectomy
• Genitourinary injury
• Blood transfusion
Major perinatal morbidity
• Fetal acidosis (cord pH <7.0)
• HIE
RISK/ 1,000 ATTEMPTED VBAC
5-7/1,000
0.4-0.7/1000
0.02/1000
Approximately 3/1000
0.5-2/1000
0.8/1000
1.8/1000
Approximately 1/1000
1.5/1000
0.4/1000
5.5.3 A previous vaginal birth reduces the risk of uterine scar rupture. 36, 37
5.5.4 The risk of uterine rupture is increased with previous classical Caesarean section (20 to
90/1,000), previous ‘inverted T’ or ‘J’ incisions (19/1,000), and low vertical incision
(20/1,000). 9 Obtaining the record of the operative note from a previous Caesarean section to
define the nature of previous scar and any significant uterine tears may be helpful in assessing
the risk of future uterine rupture. A higher incidence of scar rupture has also been reported with
induction of labour and augmentation of labour.5, 38-41 The risk of scar rupture is further
increased when prostaglandins are used to induce labour.38-40
5.5.6 A two to three-fold increase in the incidence of scar rupture has been reported if the pregnancy
interval has been less than 18 months12 or less than 24 months.12, 15 There is conflicting
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evidence as to whether single layer compared to double layer uterine closure increases the risk
of scar rupture in subsequent planned VBAC 12, 42
5.5.7 Unfortunately, ultrasound measurement of myometrial thickness has not been demonstrated to
be sufficiently predictive, or protective, of uterine rupture to be useful in clinical practice. Studies
measuring the lower segment thickness by ultrasound in late pregnancy have reported a low
incidence of subsequently detected scar defects (rupture or dehiscence) occurring with a greater
frequency in patients whose ultrasound reported a very thin lower segment; however there are
many other factors that can affect the incidence of uterine scar rupture.43-47
5.6 Perinatal Mortality
Women electing trial of labour have an increased risk of perinatal mortality compared to those undergoing
ERCS. 48 However, much of this is attributable to the often understated background rate of perinatal death
after 39 weeks gestation. Where 0.4/1,000 may have a perinatal death related to uterine rupture, a further
1.4/1,000 may be expected to have an antenatal, intrapartum or neonatal death after 39 weeks
gestation.35, 49 It is appropriate that this increase in perinatal mortality (1.8/1,000) be acknowledged in
counselling about birth options, even though mostly not a direct consequence of uterine rupture.
5.7 Hypoxic Ischemic Encephalopathy (HIE)
Landon reported 12 cases of HIE amongst 17,898 women undergoing planned VBAC (0.7/1,000), seven
cases were related to uterine rupture and five to hypoxia in labour. 33 In the same study there were no cases
of HIE in 15,801 women undergoing ERCS (p < 0.001). Children with long term neurological impairment
following uterine rupture have also been reported but the frequency is almost impossible to determine given
the absence of long term follow-up data in these retrospective series.50, 51
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5.8 Risks associated with ERCS
While Elective Caesarean section reduces the risks of some serious adverse outcomes for the baby, the
mother is exposed to surgical risks which increase with each Caesarean section that she has.
5.8.1 Neonatal Perspective
Elective Caesarean section removes the risk of late perinatal loss of the baby (1.8/1000), the risk of
HIE related to labour (0.7/1000) and reduces the risk of significant traumatic fetal injury. The risk of
fetal injury at elective Caesarean delivery is 5/1000, with the majority (71%) being a superficial skin
laceration.52 The risk of fetal intracranial injury at ERCS is very low (1:2750) when compared with
assisted vaginal delivery, forceps (1:664) and vacuum (1:860), and spontaneous vaginal delivery
(1:1900).53 The risk of brachial plexus injury from shoulder dystocia is significantly lower at
Caesarean section.54
When compared to vaginal birth, Caesarean section without labour has been associated with
increased neonatal respiratory morbidity including transient tachypnoea of the newborn, surfactant
deficiency and pulmonary hypertension. This incidence is inversely related to gestation and after 40
weeks gestation there is no difference in the incidence.55 In response to this, deferring elective
caesarean delivery in uncomplicated singleton pregnancies until 39 weeks gestation or later is
recommended by some international obstetric bodies.56-58
5.8.2 Maternal Perspective
Repeat elective Caesarean section exposes the mother to surgical risk in her current pregnancy, the
risk increasing with each subsequent Caesarean section. In a large prospective study of 30,132
women who had caesarean delivery without labour, a total of 1202 significant complications
occurred in 15,808 patients electively undergoing their second Caesarean section. As the patient’s
number of caesarean deliveries increased there was statistically significant increase in the serious
complications of severe haemorrhage (requiring more than four units of blood transfused),
hysterectomy, bladder and bowel injury and requirement for postoperative ventilation.59 Details of
these findings are presented in Appendix A.
5.8.3 Subsequent Pregnancies
An important issue to be considered in the decision analysis for many women is the intended future
family size. Silver found that placenta accreta was present in 0.24%, 0.31%, 0.57%, 2.1% and 2.3%
and 6.7% of women undergoing their first, second, third, fourth, fifth and six or more Caesarean
section deliveries respectively. 59 This is a consequence both of an increasing incidence of placenta
praevia with repeated Caesarean sections and an increased likelihood of placenta accreta where the
placenta is located over the uterine scar. The abnormally adherent placenta associated with placenta
accreta is a potentially life threatening obstetric complication that may require interventions such as
hysterectomy and high volume blood transfusion.
5.8.4 Emergency caesarean risk compared to elective caesarean section
The maternal morbidity associated with emergency Caesarean section is significantly greater than
rates reported for elective Caesarean section. Severe complications were reported in 179/1355
(13.2%) emergency Caesarean sections, compared with 80/1,141 (7%) of those delivered by elective
Caesarean section (p<0.001) in a prospective multicentre study from Finland.27 Similar results were
reported in a large Canadian study of nulliparous patients comparing outcomes of 17,714 women in
spontaneous labour at term with 721 women delivered by elective Caesarean section. 28
This increased risk of associated with the emergency Caesarean delivery needs to be considered,
especially for those patients with relatively low chance of successful VBAC, and particularly for those
women with co-existing medical morbidities.
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5.8.5 Impact on the initiation of breastfeeding
Several studies have demonstrated significantly lower rates of successful initiation of
breast feeding among women having ERCS compared to those who delivered vaginally or who have
attempted vaginal birth.29-31 It is difficult to adjust for all potential confounding variables that may
contribute to these results. Nevertheless, in view of these findings it is recommended that all possible
steps are taken to assist women having caesarean section to initiate breast feeding. This includes
promoting skin to skin contact in theatre and supporting women to breast feed as soon as practicable
after delivery, including in recovery.
5.9 Intrapartum Recommendations
Recommendation 8
Grade
Women should be advised that a planned VBAC should be conducted in a
suitably staffed and equipped delivery suite, with continuous intrapartum care
and monitoring and with available resources for urgent Caesarean section and
advanced neonatal resuscitation should complications such as scar rupture
occur
Consensus-based
recommendation
5.9.1 All women electing to labour after previous Caesarean section should have ready access to
Obstetric, Neonatal, Paediatric, Anaesthetic, operating theatre and resuscitation services
(including availability of blood products) in the event that complications occur.
5.9.2 Where, by virtue of remote location, these on-site services cannot be provided, patients should
be informed of limitations of services available and the implications for care should a uterine
rupture occur. In most circumstances this will result in either an elective repeat Caesarean
section or alternatively antenatal transfer to a centre with more comprehensive services for a trial
of labour.
Recommendation 9
Grade
Continuous intrapartum care is required to monitor progress and to enable
prompt identification and management of uterine scar rupture.
Consensus-based
recommendation
Recommendation 10
Grade
Women should be advised to have continuous electronic fetal monitoring
following the onset of uterine contractions for the duration of the planned
VBAC.
Consensus-based
recommendation
5.9.3 A woman undergoing planned VBAC should be assessed in early labour. Members of the care
team should be notified in a timely manner of the admission and of the relevant clinical
circumstances.
5.9.4 There should be continuous midwifery support and continuous electronic fetal monitoring.
5.9.5 Intravenous access should be established once labour is established and blood sent for group &
save with access to prompt crossmatch if required.
5.9.6 Oral intake should be restricted to clear fluids because of the greater than normal probability of
needing an immediate Caesarean section under general anaesthetic.
Birth after previous caesarean section
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12
5.9.7 A trial of labour mandates vigilant assessment of progress of labour with vaginal examinations
at least four hourly in the active phase of labour and more frequently as full dilatation
approaches. Two hourly assessments from 7cm dilated can be helpful to detect a secondary
arrest of labour. There needs to be evidence of progress in labour in both first and second
stage. Lack of progress should trigger clinical reassessment by an experienced obstetrician.
Recommendation 11
Grade
Epidural anaesthesia is not contraindicated in a planned VBAC.
Consensus-based
recommendation
5.9.8 Any concerns that epidural anaesthesia may mask symptoms of uterine rupture are not
considered sufficient to contraindicate epidural use. In the NICHD study, planned VBAC success
rates were higher among women who received epidural anaesthesia compared to those who did
not (73% verses 50%). 18
Recommendation 12
Grade
Early diagnosis of the serious complication of uterine scar rupture followed by
expeditious laparotomy and resuscitation is essential to reduce the associated
morbidity and mortality for mother and infant.
Consensus-based
recommendation
5.9.9 RCOG guidelines state, “There is no single pathognomic clinical feature that is indicative of
uterine rupture but the presence of any of the following peri-partum should raise the concern of
possibility of this event









Abnormal CTG (present in 55-87% of cases).
Severe abdominal pain especially persisting between contractions.
Chest pain or shoulder tip pain.
Sudden onset of shortness of breath.
Acute onset of scar tenderness.
Abnormal vaginal bleeding or haematuria.
Cessation of previous efficient uterine activity.
Maternal tachycardia, hypotension or shock.
Loss of station of the presenting part. 9”
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13
5.10 Induction and augmentation in labour
Recommendation 13
Grade
If induction of labour is required in a patient with a previous Caesarean section
the benefits and risks of a planned VBAC should be reconsidered with
alternatives discussed.
Consensus-based
recommendation
Recommendation 14
Grade
Prostaglandins are not recommended for the induction of planned VBAC at
term.
Consensus-based
recommendation
Recommendation 15
Grade
Augmentation of labour with Syntocinon in planned VBAC should be performed
with caution and be a consultant led discussion with the risks and benefits
discussed with the patient then documented in the clinical record.
Consensus-based
recommendation
5.10.1 Induction of labour for maternal or fetal indications remains an option for women undergoing
planned VBAC, however induction of labour reduces the success rate of achieving VBAC and
increases the rate of uterine rupture. Induced labour is less likely to result in VBAC than
spontaneous labour and an unfavourable cervix at induction decreases the chances of
success.18, 40, 41, 60-63
5.10.2 In the large NICHD study of 17,898 women undergoing planned VBAC, the rates of
intrapartum Caesarean section were 33%, 26% and 18% for induced, augmented and
spontaneous labour groups respectively. The risk of uterine rupture per 10,000 planned
VBAC’s was 102, 87, and 36 for induced, augmented and spontaneous labour groups.18, 33
5.10.3 Several studies have reported high rates (1.4 to 2.45%) of uterine rupture when labour has
been induced using prostaglandins. 33, 38, 40
5.10.4 Information regarding the effectiveness and safety of transcervical catheters in planned VBAC is
limited due to small sample sizes in the studies and valid conclusions are not possible.3 Two
studies showed no risk of uterine rupture, whereas another reported an increased risk
compared to women in spontaneous labour.20, 40 64 It is not clear whether any increased risk
may be associated with an unfavourable cervix.
5.10.5 The use of oxytocin for augmentation of contractions, separate from induction of labour during
planned VBAC, has been examined in several studies. Some have found an association
between oxytocin augmentation and the uterine rupture where others have not.5, 33, 62, 63 In an
Australian retrospective cohort study Dekker reported a 14 fold difference in the adjusted odds
ratio for uterine rupture in planned VBAC patients in spontaneous onset of labour augmented
with Syntocinon (12/628, 1.9%) compared to those without augmentation with Syntocinon
(16/8221, 0.19%).
5.10.6 The decision to augment labour in planned VBAC appropriately should involve a consultant
Obstetrician after clinical assessment of the case and discussion with the patient. Oxytocin
should be titrated in such a way that adequate uterine activity is obtained but that there be no
more than four contractions in 10 minutes. Careful cervical assessments, preferably by the
same person, are required to show adequate progress thereby allowing augmentation to
continue. The interval for serial vaginal examinations and selected parameters of progress
that would necessitate discontinuing the labour should be consultant led decisions.
Birth after previous caesarean section
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14
5.10.7 When informing a woman about induction and/or augmentation of labour, clear information
regarding potential risks and benefits should be provided. Some women who are
contemplating future pregnancies may accept short term additional risks associated with
induction and/or augmentation in view of the reduced risk of serious complications for future
pregnancies if they achieve a successful VBAC.
6.
Special Circumstances
6.1 Trial of labour after more than one previous Caesarean section
Studies comparing outcomes of planned VBAC for patients who have had two or more Caesarean sections
generally have reported significantly lower success rates for achieving VBAC, higher rates of uterine rupture
or scar dehiscence, and a greater incidence of major maternal morbidity when compared to patients with
only one previous Caesarean section. A meta-analysis published in 2009 reported a significantly lower
success rate for VBAC (71% vs 77%,p<0.001) and higher rupture rate (1.6% vs 0.7%, p<0.001) when the
outcomes of planned VBAC after two previous caesarean sections were compared to those patients with one
previous caesarean section. The meta-analysis reported a similar maternal morbidity for the patients
undergoing VBAC after two previous caesarean sections compared with those undergoing a third ERCS.65
The details of some individual studies are summarised in Appendix B.
Attitudes of Obstetricians and patients may vary in different regions. RCOG state that a patient with two
previous uncomplicated caesarean sections in an uncomplicated pregnancy at term, “who has been fully
informed by consultant Obstetrician may be considered suitable for planned VBAC”. 9 However, RCOG
recommends that three previous Caesarean sections is a contraindication to planned VBAC. SOGC state
“available data suggests that a trial of labour with more than one previous Caesarean section is likely to be
successful, but is associated with a higher risk of uterine rupture”.11
6.2 Twin Gestation
A cautious approach is advocated in twin pregnancies who are considering planned VBAC. There is some
uncertainty regarding the safety and efficacy of planned VBAC in a twin pregnancy.
Success rates of vaginal birth of between 64% and 76% without an increase in scar rupture or perinatal
morbidity have been reported in three small studies; Varner (n=412), Cahill (n=535) and Miller (n=210).
66-68
The largest study reported a successful VBAC rate of 45% of 1850 twin pregnancies undergoing
planned VBAC and a scar rupture rate of 0.9%. This study did not provide any neonatal outcome data.69
Birth after previous caesarean section
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15
6.3 Mid-trimester delivery
Patients who have previously been delivered by Caesarean section and require delivery in the mid-trimester
due to fetal abnormality or fetal demise have three options: hysterotomy; dilatation and evacuation (D&E);
or, medical induction of labour. There have been no randomised trials comparing the outcomes from these
options.
Misoprostol, a synthetic analogue of Prostaglandin E 1 , has been successful when used in the mid-trimester
both for patients with an unscarred uterus and for those with a scarred uterus.70-72 Goyal, in a 2009
systematic review of 16 studies, reported a rupture rate of 1/2384 (0.04%) in patients with no uterine scar
and 2/722 (0.28%) in patients with one or more prior Caesarean sections. When misoprostol was the sole
agent used to induce labour (seven studies) there were no uterine ruptures in 256 patients with prior
caesarean delivery. When the more recent studies of Gulec (2013) and Berghella (2009) are combined a
scar rupture rate of 2/104 (1.9%) occurred in patients with one previous caesarean section and 3/79 (3.7%)
in those with two or more caesarean sections. There has been a wide variation in dosage and method of
administration of misoprostol in the reported series.71, 72
Due to the limitations of the studies available Dodd and Crowther in a Cochrane review 2010 entitled
“Misoprostol for induction of labour to terminate pregnancy in the second or third trimester for women with
a fetal abnormality or after intrauterine fetal death” stated “ important information regarding maternal
safety, in particular the occurrence of rare outcomes such as uterine rupture, remains limited.”73
Use of misoprostol (alone or combined with mifepristone) to induce labour in the second trimester would
appear to be a reasonable option in women with prior caesarean delivery. Another option is mechanical
cervical ripening with a balloon catheter (alone or combined with mifepristone) and carefully monitored
syntocinon induction of labour. The decision between these methods will be determined by gestational age,
cervical favourability, number and type of caesarean section scar/s and clinician experience. These labours
require close surveillance and senior clinical oversight.
7.
Conclusion
Recommendation 16
Grade
Pregnancy after Caesarean section should be subject to multi-disciplinary
clinical audit, including assessment of the number of women opting for planned
VBAC versus ERCS as well as the number achieving VBAC. Quality of
adherence to agreed protocols should form part of the clinical audit.
Consensus-based
recommendation
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16
USEFUL LINKS USED IN THE WRITING OF THIS STATEMENT

RCOG Greentop Guidelines No.45 (2007); Birth after Previous Caesarean section.
https://www.rcog.org.uk/globalassets/documents/guidelines/gtg4511022011.pdf.

ACOG Clinical Management Guidelines (Vaginal Birth after Previous Caesarean Section 2010);
http://www.acog.org/Resources-And-Publications/Practice-Bulletins/Committee-on-PracticeBulletins-Obstetrics/Vaginal-Birth-After-Previous-Cesarean-Delivery.

SOGC Clinical Practice Guidelines; Guidelines for Vaginal Birth after Previous Caesarean Birth
(2004); http://sogc.org/wp-content/uploads/2013/01/155E-CPG-February2005.pdf.

SA Perinatal Practice Guidelines; (Birth options after Caesarean Section);
http://www.sahealth.sa.gov.au/wps/wcm/connect/98d6ab804ee1e002ad49add150ce4f37/Birth
+options+after+caesarean+sectionPPG_june+2014.pdf?MOD=AJPERES&CACHEID=98d6ab8
04ee1e002ad49add150ce4f37.
LINKS TO OTHER COLLEGE STATEMENTS
Intrapartum Fetal Surveillance Clinical Guideline (3rd edition)
http://www.ranzcog.edu.au/doc/Intrapartum%20Fetal%20Surveillance%20Clinical%20Guideline%20%20Third%20Edition.html
Placenta Accreta (C-Obs 20)
http://www.ranzcog.edu.au/component/docman/doc_download/954-placenta-accreta-c-obs20.html?Itemid=946
Timing of Elective Caesarean Section (C-Obs 23)
http://www.ranzcog.edu.au/component/docman/doc_download/956-timing-of-elective-caesarean-sectionat-term-c-obs-23.html?Itemid=946
Delivery of the Fetus at Caesarean Section (C-Obs 37)
http://www.ranzcog.edu.au/component/docman/doc_download/970-delivery-of-the-fetus-at-caesareansection-c-obs-37.html?Itemid=946
Caesarean Delivery on Maternal Request (CDMR) (C-Obs 39)
http://www.ranzcog.edu.au/component/docman/doc_download/972-caesarean-delivery-on-maternalrequest-cdmr-c-obs-39.html?Itemid=946\
Perinatal Anxiety and Depression (C-Obs 48)
http://www.ranzcog.edu.au/component/docman/doc_download/1171-perinatal-anxiety-and-depression-cobs-48.html?Itemid=946
Consent and the Provision of Information to Patients in Australia regarding Proposed Treatment (C-Gen
02a) http://www.ranzcog.edu.au/component/docman/doc_download/899-consent-and-the-provision-ofinformation-to-patients-in-australia-regarding-proposed-treatment-c-gen-02a.html?Itemid=946
Birth after previous caesarean section
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Consent and the Provision of Information to Patients in Australia regarding Proposed Treatment (C-Gen
02b) http://www.ranzcog.edu.au/component/docman/doc_download/1460-consent-and-provision-ofinformation-to-patients-in-new-zealand-regarding-proposed-treatment-c-gen-02b.html?Itemid=946
Evidence-based Medicine, Obstetrics and Gynaecology (C-Gen 15)
http://www.ranzcog.edu.au/component/docman/doc_download/894-c-gen-15-evidence-based-medicineobstetrics-and-gynaecology.html?Itemid=341
Birth after previous caesarean section
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18
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caesarean sections, BJOG. 2010;117(1):5-19.
Varner MW, Leindecker S, Spong CY, Moawad AH, Hauth JC, Landon MB, et al. The MaternalFetal Medicine Unit cesarean registry: trial of labor with a twin gestation, Am J Obstet Gynecol.
2005;193(1):135-40.
Cahill A, Stamilio DM, Pare E, Peipert JP, Stevens EJ, Nelson DB, et al. Vaginal birth after cesarean
(VBAC) attempt in twin pregnancies: is it safe?, Am J Obstet Gynecol. 2005;193(3 Pt 2):1050-5.
Miller DA, Mullin P, Hou D, Paul RH. Vaginal birth after cesarean section in twin gestation, Am J
Obstet Gynecol. 1996;175(1):194-8.
Ford AA, Bateman BT, Simpson LL. Vaginal birth after cesarean delivery in twin gestations: a large,
nationwide sample of deliveries, Am J Obstet Gynecol. 2006;195(4):1138-42.
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70.
71.
72.
73.
Goyal V. Uterine rupture in second-trimester misoprostol-induced abortion after cesarean delivery:
a systematic review, Obstet Gynecol. 2009;113(5):1117-23.
Kücükgöz Gülec U, Urunsak IF, Eser E, Guzel AB, Ozgunen FT, Evruke IC, et al. Misoprostol for
midtrimester termination of pregnancy in women with 1 or more prior cesarean deliveries. 2003.
Berghella V, Airoldi J, O'Neill AM, Einhorn K, Hoffman M. Misoprostol for second trimester
pregnancy termination in women with prior caesarean: a systematic review, BJOG.
2009;116(9):1151-7.
Dodd JM, Crowther CA. Misoprostol for induction of labour to terminate pregnancy in the second
or third trimester for women with a fetal anomaly or after intrauterine fetal death, Cochrane
Database Syst Rev. 2010(4):CD004901.
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Appendices
Appendix A Maternal Morbidity of Women Who Had Caesarean Deliveries Without Labour 59
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Appendix B Outcomes of VBAC comparing patients with one previous caesarean section with those multiple
previous caesarean sections.
STUDY
STRUCTURE
(Numbers of patients
undergoing planned
VBAC)
SUCCESS RATE
FOR VBAC (%)
RATE OF SCAR
BREAKDOWN (%)
(p value)
(STATISTICS)
SIGNIFICANT
INCREASE IN
MAJOR
MATERNAL
MORBIDITY
REPORTED IF
>1 CAESAREAN
SECTION
LANDON et.al
(2006)
Prospective (USA)
1 previous LUSCS
(16,915)
74%
0.7%
(p<0.001)
(NS)
66%
0.9%
76%
0.72%
(p<0.001)
(p<0.001)
71%
1.59%
1 previous LUSCS
(1,110)
71%
1.1%
(p<0.05)
(NS)
≥ 2 previous LUSCS
(302)
64%
1.9%
1 previous LUSCS
(3,757)
75%
0.8%
(p=0.001)
(p=0.001)
2 previous LUSCS
(134)
62%
3.7%
≥ 2 previous LUSCS
(648)
TAHSEEN AND
GRIFFITHS (2009)
Literature Review
(Case and Cohort
Studies)
1 previous LUSCS
(50,685)
2 previous LUSCS
(4,564)
ASA KURA AND
MYERS (1995)
CAUGHEY et.al
(1999)
Yes
No
Retrospective (USA)
No
Retrospective (USA)
Yes
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MACONES et.al
Retrospective (USA)
(2005)
1 previous LUSCS
(12,535)
76%
0.9%
(NS)
(OR=2.0 95% CI
1.24 – 3.27)
2 previous LUSCS
(1,082)
75%
1.8%
Yes
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Appendix C Women’s Health Committee Membership
Name
Associate Professor Stephen Robson
Dr James Harvey
Associate Professor Anusch Yazdani
Associate Professor Ian Pettigrew
Dr Ian Page
Professor Yee Leung
Professor Sue Walker
Dr Lisa Hui
Dr Joseph Sgroi
Dr Marilyn Clarke
Dr Donald Clark
Associate Professor Janet Vaughan
Dr Benjamin Bopp
Associate Professor Kirsten Black
Dr Jacqueline Boyle
Dr Martin Byrne
Ms Catherine Whitby
Ms Sherryn Elworthy
Dr Nicola Denton
Position on Committee
Chair and Board Member
Deputy Chair and Councillor
Member and Councillor
Member and Councillor
Member and Councillor
Member of EAC Committee
General Member
General Member
General Member
General Member
General Member
General Member
General Member
General Member
Chair of the ATSIWHC
GPOAC representative
Community representative
Midwifery representative
Trainee representative
Appendix D Overview of the development and review process for this statement
i.
Steps in developing and updating this statement
This statement was originally developed in July 2010 and was most recently reviewed in July 2015. The
Women’s Health Committee carried out the following steps in reviewing this statement:
ii.
•
Declarations of interest were sought from all members prior to reviewing this statement.
•
Structured clinical questions were developed and agreed upon.
•
An updated literature search to answer the clinical questions was undertaken.
•
At the July 2015 face-to-face committee meeting, the existing consensus-based
recommendations were reviewed and updated (where appropriate) based on the available
body of evidence and clinical expertise. Recommendations were graded as set out below in
Appendix B part iii)
Declaration of interest process and management
Declaring interests is essential in order to prevent any potential conflict between the private interests of
members, and their duties as part of the Women’s Health Committee.
A declaration of interest form specific to guidelines and statements was developed by RANZCOG and
approved by the RANZCOG Board in September 2012. The Women’s Health Committee members
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were required to declare their relevant interests in writing on this form prior to participating in the review
of this statement.
Members were required to update their information as soon as they become aware of any changes to
their interests and there was also a standing agenda item at each meeting where declarations of interest
were called for and recorded as part of the meeting minutes.
There were no significant real or perceived conflicts of interest that required management during the
process of updating this statement.
iii. Grading of recommendations
Each recommendation in this College statement is given an overall grade as per the table below, based
on the National Health and Medical Research Council (NHMRC) Levels of Evidence and Grades of
Recommendations for Developers of Guidelines. Where no robust evidence was available but there was
sufficient consensus within the Women’s Health Committee, consensus-based recommendations were
developed or existing ones updated and are identifiable as such. Consensus-based recommendations
were agreed to by the entire committee. Good Practice Notes are highlighted throughout and provide
practical guidance to facilitate implementation. These were also developed through consensus of the
entire committee.
Recommendation category
Description
Evidence-based
A
Body of evidence can be trusted to guide practice
B
Body of evidence can be trusted to guide practice in most
situations
C
Body of evidence provides some support for
recommendation(s) but care should be taken in its
application
D
The body of evidence is weak and the recommendation
must be applied with caution
Consensus-based
Recommendation based on clinical opinion and expertise
as insufficient evidence available
Good Practice Note
Practical advice and information based on clinical opinion
and expertise
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Appendix E Full Disclaimer
This information is intended to provide general advice to practitioners, and should not be relied on as a
substitute for proper assessment with respect to the particular circumstances of each case and the needs of
any patient.
This information has been prepared having regard to general circumstances. It is the responsibility of each
practitioner to have regard to the particular circumstances of each case. Clinical management should be
responsive to the needs of the individual patient and the particular circumstances of each case.
This information has been prepared having regard to the information available at the time of its preparation,
and each practitioner should have regard to relevant information, research or material which may have
been published or become available subsequently.
Whilst the College endeavours to ensure that information is accurate and current at the time of preparation,
it takes no responsibility for matters arising from changed circumstances or information or material that may
have become subsequently available.
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